Out-of-Hospital Premises Inspection Program
These standards apply to all physicians performing applicable procedures in an Out-of-Hospital Premise (OHP).
Providing Notice
The regulation applies to any physician performing or intending to perform procedures in an OHP under the administration of:
- General anesthesia;
- Parenteral sedation (administered by intravenous, intramuscular or subcutaneous injection);
- Regional anesthesia (except for a digital nerve block); or
- A local anesthetic agent, including, but not limited to:
- any tumescent procedure involving the administration of dilute, local anesthetic;
- surgical alteration or excision of any lesions or tissue performed for cosmetic purposes;
- injection or insertion of any permanent filler, autologous tissue, synthetic device, materials or substances for cosmetic purposes;
- a nerve block solely for the treatment or management of chronic pain; or
- any act that is similar in nature to those set out above and performed for a cosmetic purpose.
Before you perform these procedures at an OHP, you must complete the notification form, pay the $75 fee and pass a premise inspection, which we conduct within 180 days of receiving your notice.
You do not have to notify the College if you are only performing the following procedures at the OHP:
- Surgical alteration or excision of lesions or tissue for a clinical purpose, including examination, treatment or diagnosis of disease;
- Minor dermatological procedures including, but not limited to, the removal of skin tags, benign moles and cysts, nevi, seborrheic keratoses, fibroepithelial polyps, hemangioma and neurofibromata;
- Lasik surgeries; or
- Cosmetic procedures not involving general, regional or parenteral anesthesia including, but not limited to, temporary fillers, laser skin resurfacing, botox and sclerotherapy.
OHPIP Standards
The Out-of-Hospital Premises Inspection Program (OHPIP) standards and companion documents outline core requirements for the performance of specific procedures in OHPs that do not fall under another regulatory oversight system.
Change of Status
After an OHP receives their final rating, the medical director is responsible for notifying the CPSO of any changes to their premises, including:
- Adding new procedures;
- Changing the OHP level;
- Renovating;
- Moving to a new location;
- Renting space to other physicians; and/or
- Ceasing operations.
You must complete a status change report form with as many details as possible so the CPSO can decide if you need a follow-up inspection. Your premise is only permitted to perform procedure(s) disclosed during your initial inspection-assessment and you must wait for the CPSO’s approval before implementing any changes.
Note: We will invoice OHPs for subsequent, follow-up assessments outside of the scheduled assessment cycle.
Adverse Events Reporting
The CPSO requires OHPs to report adverse events via the appropriate adverse events form in the members’ portal.
Tier 1 Events
Physicians must report the following events within 24 hours of their knowledge of the event:
- Death within the premises;
- Death within 10 days of a procedure performed at the premises;
- Any procedure performed on wrong patient, site or side; and/or
- Transfer of a patient from the premises directly to a hospital for care.
Upon receipt of the report, the College will decide if further action is required, such as a re-assessment of the premises.
Tier 2 Events
Medical directors must document events for quality improvement purposes and report them annually to the CPSO including, but not limited to:
- An unscheduled treatment of a patient in a hospital within 10 days of the procedure performed at a premise;
- A complication, such as infection, bleeding or injury to other body structures;
- A cardiac or respiratory problem during the patient’s stay at the OHP;
- An allergic reaction; and/or
- A medication-related adverse event.
If you have any questions or need assistance, please email OHPIP.
Accreditation Program Contacts
Laurie Reid
Director, Investigations and Accreditation Program
[email protected]
Christine Grusys
Supervisor, Accreditation Program
[email protected]
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NOTE: Please ensure you open and complete the forms in the latest version of Adobe Reader; otherwise entered text may not save.
- Facility Questionnaire
- Premises Standards Checklist
- Physician Observational Component: Clinical Observation Form
- Patient Chart Assessment Checklist
- Adult Chronic Pain Management: Clinical Observation Form
- Patient Chart Assessment Checklist: Interventional Pain Management
- Anesthesia Chart Assessment Checklist
- Adult Chronic Pain Management Premises
- Endoscopy/Colonoscopy Checklist
- Induced Abortion Checklist
- Sample Quality Assurance Minutes
Completed by the Medical Director
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